BICEPS, TENDON TEARS, AND SLAP LESIONS
The classic “Popeye” deformity of the biceps muscle is associated with rupture of the long head of the biceps muscle proximally in the shoulder at the level of the bicipital groove. When the tendon retracts from its origin, the muscle shortens, resulting in a “bunching up” of the muscle belly. This is a common condition often associated with rotator cuff tears or impingement syndrome (see Plate 1-41). In many cases, persistent shoulder symptoms after biceps tendon rupture are related to the associated rotator cuff pathologic process rather than symptoms associated with the biceps tendon tear. If shoulder symptoms persist after long head of the biceps tendon rupture, then evaluation of the rotator cuff with magnetic resonance imaging (MRI) or ultra- sonography of the shoulder is warranted. In some patients, although uncommon, isolated tear of the long head of the biceps can result in aching discomfort or cramping of the biceps for forceful elbow flexion or supination of the forearm, both of which are functions of the biceps muscle. Most isolated tears of the long head of the biceps are asymptomatic, and for this reason most are not treated by surgical repair, particularly in the older or more sedentary patient. Isolated acute tears in the younger and active patient in some cases should be considered for surgical repair. When surgically repaired, the torn end of the long head of the biceps tendon is sutured within the biceps groove using a suture anchor. Alternatively, the tendon can be sutured to local soft tissues such as the pectoralis major tendon or the short head of the biceps. This procedure is called a biceps tenodesis and is most often performed by arthroscopic means when the tendon is released from its origin at the time of surgery when performed electively for treatment of a biceps tendon lesion or a lesion of the superior labrum from anterior to posterior (SLAP lesion) involving the long head of the biceps.
When a tenodesis is performed for management of an acute rupture, the repair is more often performed by open surgery through a small deltopectoral or subpectoral incision. In cases in which a biceps or superior labrum pathologic process involving the biceps is found at the time of surgery for an isolated biceps pathologic process or when it is associated with rotator cuff pathology in an older or more sedentary patient, the long head of the biceps tendon is released at the site of its origin and allowed to retract without repair. Although this will result in a “Popeye” deformity, the patient is most often asymptomatic and the pain that was preoperatively associated with the long head of the biceps is relieved. The biceps tendon is attached to the superior labrum both anteriorly and posteriorly. Type I SLAP lesions are common and often associated with the normal aging process and as such are not often associated with sig- nificant pathology or symptoms. Similarly, when type II lesions are typically seen in the older age population they are often asymptomatic. Type II SLAP lesions can be symptomatic when they are acute and traumatic. They are often seen after a fall onto an outstretched arm or in the overhead-throwing athlete as related to repetitive trauma and may warrant a surgical repair. Type III lesions involve a bucket-handle tear of the labrum with mechanical symptoms without biceps tendon involvement and are amenable to surgical treat- ment specifically to remove that portion of the labrum that is detached. Type IV SLAP lesions involve both the superior labrum and the long head of the biceps tendon. These lesions are often symptomatic and are generally treated by removal of the labral tissue and with tenodesis of the biceps. Alternatively, the biceps tendon and type IV SLAP lesion can be repaired if tendon quality is good and the lesion is relatively small. Less common types of SLAP lesions are associated with tears extending into the anterior inferior labrum (Bankart-type labrum tears) and are associated with glenohumeral instability. In these cases, when symptomatic, both lesions are repaired at the time of surgery, most commonly with arthroscopic techniques.
Diagnosis of SLAP lesions is performed with a variety of maneuvers, including the O’Brien sign. The O’Brien sign is performed with a series of three maneuvers as shown and described in Plate 1-35. A positive test for a SLAP lesion results in pain in the anterior aspects of the shoulder with a resisted forward elevation. These symptoms are less so with the arm in external rotation and also not significantly present with the arm in internal rotation but in the plane of the scapula.